Pediatrics and Neonatology | Interesting Rare Cases | Kauvery Hospital
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‘ATYPICAL PRESENTATION OF ATYPICAL ORGANISM’

Case Report:

A six year old girl, who was pre-morbidly well, presented to our emergency department on day 6 of illness. She presented with high grade intermittent fever for 6 days associated with periumblical abdominal pain, non-bilious vomiting and loose stools for a day. There was history of mild cough since day 3 of illness. There was no other associated systemic symptoms.

She was febrile and tachypneic at presentation, with signs of compensated shock. Her Q-SOFA score was three, indicating severe illness. She was resuscitated with intravenous crystalloids, oxygen and inotropes. She was started on intravenous antibiotics after obtaining blood for aerobic culture. Her abdominal examination revealed mild hepatomegaly and her other systemic examinations were normal. She was admitted in our Paediatric intensive care unit. Infectious causes like Severe sepsis / Enteric fever / scrub typhus with features of compensated shock were differentials considered clinically.
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Mycoplasma , the smallest free-living microorganisms are ubiquitous in nature. Of this group, seventeen have been identified as human pathogens. Mycoplasma pneumoniae, Mycoplasma hominis, and Ureaplasma urealyticum found to cause disease frequently in children. M. pneumonia ferments carbohydrates and requires sterol for growth. It grows under both anaerobic and aerobic conditions, but growth is more consistent when it is incubated in nitrogen and 5 percent carbon dioxide. When compared with other mycoplasmas isolated from humans, M. pneumoniae grows relatively slowly, with visible formation of colonies rarely occurring in less than 1 week and possibly taking 3 weeks or more.

M. pneumoniae affects respiratory system commonly, however there numerous extra-pulmonary manifestations were documented. Pulmonary and extrapulmonary manifestations were tabulated below (table-1). Gastrointestinal manifestations including hepatitis, acute acalculous cholecystitis, and pancreatitis have been reported. Elevated liver enzymes are rarely observed during M. pneumoniae infection in children. Liver involvement was transitory in these patients, and recovery of liver enzymes to normal range correlated directly with resolution of mycoplasma pneumonia, as demonstrated in our patient.

Pulmonary and extr-pulmonary manifestations of Mycoplasma pneumonia

PULMONARY CARDOVASCULAR SKIN BLOOD GASTRO-INTESINAL CNS MUSCULO-SKELETAL
  • Pharyngitis
  • Otitis media
  • Croup
  • Bronchitis
  • Infectious asthma
  • Pneumonia
  • Pericarditis
  • Perimyocarditis
  • Secondary heart block
  • Macuopapularrash
  • Steven Johnson syndrome
  • Vesicobulous lesion
  • Erythemamultiformae
  • Urticaria
  • Blotchy erythema
  • varicella like lesions
  • Hemolytic anemia
  • Thrombocyto penia
  • Disseminated Intravascular coagulation
  • Secondary heophagocyt-osis
  • Hepatitis
  • Cholecystitis
  • Pancreatitis
  • Splenic infarct
  • Aseptic meningitis
  • Rye-like illness
  • Cerebral Infarct
  • Psychosis
  • Radiculopathy
  • ADEM
  • Arthritis
  • Polymyositis
  • Rhabdomyoysis
  • Leucocytocla stic vasculitis

Mycoplasma can be detected easily by cold agglutinin method, detection of IgM / IgA antibodies by ELISA method and also polymerase chain reaction method. Azithromycin and clarithromycin both are approved for the treatment of community-acquired pneumonia and severe disease in children. In more serious illness such as Stevens-Johnson syndrome and neurologic disease, individual case studies have indicated little evidence of therapeutic benefit with either erythromycin or tetracycline therapy. Corticosteroids have been used in severe conditions like steven Johnson, neurological manifestation, severe pneumonia and hemoytic anemia.

Hence we report a case of Severe mycoplasma pneumonaie infection with atypical manifestations- severe pneumonai associated with hepatitis, thrombocytopenia and coagulopathy, who recovered well with adequate intravenous azithromycin therapy. We conclude that Mycoplasma infection should be considered as differential in atypical extrapulmonary clinical manifestations as listed above.

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